A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take?
Sit at or below the client's eye level during feedings.
Instruct the client to lift her chin when swallowing.
Talk with the client during her feeding.
Discourage the client from coughing during feedings.
The Correct Answer is A
Rationale:
A. Sit at or below the client's eye level during feedings: Positioning the nurse at or slightly below the client’s eye level promotes effective communication and allows close observation of swallowing. It helps the nurse monitor for signs of aspiration, coughing, or choking, which is critical in clients with dysphagia to ensure safety during meals.
B. Instruct the client to lift her chin when swallowing: Clients with dysphagia should be taught to tuck the chin slightly toward the chest, not lift it, to protect the airway and facilitate safer swallowing. Lifting the chin increases the risk of aspiration and airway compromise.
C. Talk with the client during her feeding: Talking while swallowing increases the risk of aspiration because it distracts the client and can disrupt coordinated swallowing. Silence and focused attention are recommended during feeding to ensure safe intake of food and liquids.
D. Discourage the client from coughing during feedings: Coughing is a protective reflex that clears the airway if food or liquid enters the trachea. Discouraging it could increase the risk of aspiration and choking, making it unsafe to suppress this natural defense mechanism.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Fidelity: Fidelity refers to being faithful to commitments and maintaining trust in professional relationships. While important in nursing, it does not specifically relate to equitable distribution of community resources.
B. Autonomy: Autonomy emphasizes respecting an individual’s right to make informed decisions about their own care. Planning a program to ensure equal access addresses fairness, not individual decision-making.
C. Justice: Justice involves fairness in the distribution of resources, benefits, and risks. By ensuring prenatal resources are equally available to all community members, the nurse is practicing the ethical principle of justice and promoting equity in healthcare access.
D. Nonmaleficence: Nonmaleficence focuses on preventing harm to clients. While relevant to all nursing practice, it is not the primary principle guiding equitable allocation of prenatal resources in the community.
Correct Answer is B
Explanation
Rationale:
A. Strabismus: Strabismus, or misalignment of the eyes, is not a known adverse effect of timolol. Timolol primarily affects intraocular pressure and systemic cardiovascular parameters rather than eye muscle alignment.
B. Bradycardia: Timolol is a nonselective beta-adrenergic blocker that can be absorbed systemically even when administered as eye drops. One potential systemic adverse effect is bradycardia, as the medication can reduce heart rate and cardiac output, particularly in clients with preexisting heart conditions.
C. Conjunctivitis: While eye irritation or mild stinging can occur with timolol, conjunctivitis is not a typical adverse effect. Instructing clients to monitor for more common ocular side effects, such as burning or discomfort, is appropriate.
D. Hyperglycemia: Timolol does not typically cause hyperglycemia. Beta-blockers can sometimes mask hypoglycemia symptoms in diabetic clients but are not associated with raising blood glucose levels directly.
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